Sarah Wakeman, MD, FASAM, Medical Director, Massachusetts General Hospital Substance Use Disorder Initiative – Harvard Health Bloghttps://www.health.harvard.edu/blog
Harvard Health Blog: You’ll find posts from Harvard Medical School physicians and our editors on a variety of health news and issues.Fri, 10 Aug 2018 18:00:25 +0000en-US
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102120Harvard Health Blog: You’ll find posts from Harvard Medical School physicians and our editors on a variety of health news and issues.Lofexidine: Another option for withdrawal from opioids, but is it better?https://www.health.harvard.edu/blog/lofexidine-another-option-for-withdrawal-from-opioids-but-is-it-better-2018060614515
Wed, 06 Jun 2018 10:30:11 +0000https://www.health.harvard.edu/blog/?p=14515Recently the FDA approved a medication called lofexidine (Lucemyra) for the treatment of opioid withdrawal. Lofexidine is in a class of medications called alpha-2-adrenergic agonists, which act on the nervous system and can cause sedation, mild pain relief, and relaxation. This class of medications has been used to treat common medical conditions like high blood […]

Recently the FDA approved a medication called lofexidine (Lucemyra) for the treatment of opioid withdrawal. Lofexidine is in a class of medications called alpha-2-adrenergic agonists, which act on the nervous system and can cause sedation, mild pain relief, and relaxation. This class of medications has been used to treat common medical conditions like high blood pressure or anxiety. They have also been used for decades to ameliorate the symptoms of opioid withdrawal. The more commonly used medication in this group is called clonidine and has been a staple for medically supervised withdrawal. Lofexidine is very similar to clonidine, with one exception: clonidine can cause low blood pressure, which can be a limiting side effect, whereas lofexidine has less of an impact on blood pressure.

How does lofexidine compare to other medications used for withdrawal?

So lofexidine is slightly safer, but does it work? Well, that depends on what you compare it to. Compared to no medication or a placebo, both lofexidine and clonidine are more effective at relieving withdrawal symptoms. However, being better than no treatment is not exactly a winning endorsement. The real question is whether lofexidine is better than standard of care treatment with medications like buprenorphine or methadone. Buprenorphine and methadone are both opioid agonists, meaning they exert activity at the same receptor that all opioids do. This makes them effective at resolving withdrawal symptoms, and also at relieving cravings and reducing the likelihood of relapse and overdose if used in an ongoing way.

When compared to tapering doses of methadone used for medically supervised withdrawal, peak withdrawal severity was worse with lofexidine, meaning people treated with lofexidine instead of methadone were more likely to have severe withdrawal, and reported higher peak scores for withdrawal symptoms. However, overall the withdrawal symptoms resolved sooner with lofexidine compared to methadone, and treatment was shorter.

Can this medication help reduce overdose deaths or help people stay in treatment?

The rub here is that medically supervised withdrawal with methadone or buprenorphine is also not standard of care. A majority of people will relapse after medically supervised withdrawal (often referred to as “detox”). In contrast, being treated long-term with either methadone or buprenorphine as a maintenance medication treatment reduces the risk of relapse and overdose death by more than 50% while increasing the likelihood of staying engaged in treatment.

For example, one seminal paper published in the Lancet randomly assigned a small group of individuals with opioid use disorder to either medically supervised withdrawal followed by a year of intensive psychosocial treatment, or a year of buprenorphine with psychosocial treatment. In the group assigned to medically supervised withdrawal, no one stayed in treatment and 20% were dead at the end of the year. In contrast, in the group assigned to buprenorphine, 75% were abstinent and no one died. These are dramatic differences calling into question any practice of medically supervised withdrawal as an effective intervention for opioid use disorder.

Lofexidine may be an option before starting extended-release naltrexone

One group of patients who do require medically supervised withdrawal are those who want to start extended-release naltrexone, a third FDA-approved medication for the treatment of opioid use disorder. Unlike methadone and buprenorphine, naltrexone does not activate the opioid receptor, but rather blocks it to prevent the effects of other opioids. People have to be opioid-free for seven to 10 days prior to starting naltrexone, which leads to fewer people being able to successfully start treatment. This is one of the main reasons that extended-release naltrexone is less effective than buprenorphine treatment. However, for patients who choose extended-release naltrexone, effective non-opioid options for withdrawal management are important, and this may be where lofexidine is particularly helpful.

So what’s the bottom line? The most effective treatments we have for opioid use disorder treatment are long-term medication maintenance with methadone or buprenorphine, and for select patients extended-release naltrexone. For patients choosing medically supervised withdrawal, methadone and buprenorphine are still the most effective, but lofexidine may be an important option for patients undergoing withdrawal with the intent of starting extended-release naltrexone.

]]>14515https://www.facebook.com/sharer/sharer.php?u=https%3A%2F%2Fwww.health.harvard.edu%2Fblog%2Flofexidine-another-option-for-withdrawal-from-opioids-but-is-it-better-2018060614515]]>Another option for life-threatening allergic reactionshttps://www.health.harvard.edu/blog/another-option-for-life-threatening-allergic-reactions-2018010813052https://hhp-blog.s3.amazonaws.com/2018/08/perscription-bottles-pills-300x200.jpg2018-06-06 06:30:112018-06-06 10:30:11If cannabis becomes a problem: How to manage withdrawalhttps://www.health.harvard.edu/blog/if-cannabis-becomes-a-problem-how-to-manage-withdrawal-2020052619922https://hhp-blog.s3.amazonaws.com/2018/08/perscription-bottles-pills-300x200.jpg2018-06-06 06:30:112018-06-06 10:30:11Fish consumption and rheumatoid arthritis: Natural remedy or just another fish tale?https://www.health.harvard.edu/blog/fish-consumption-and-rheumatoid-arthritis-natural-remedy-or-just-another-fish-tale-2017082812299https://hhp-blog.s3.amazonaws.com/2018/08/perscription-bottles-pills-300x200.jpg2018-06-06 06:30:112018-06-06 10:30:11Art therapy: Another way to help manage painhttps://www.health.harvard.edu/blog/art-therapy-another-way-to-help-manage-pain-2018071214243https://hhp-blog.s3.amazonaws.com/2018/08/perscription-bottles-pills-300x200.jpg2018-06-06 06:30:112018-06-06 10:30:11MitraClip: Valve repair device offers new treatment option for some with severe mitral regurgitationhttps://www.health.harvard.edu/blog/mitraclip-valve-repair-device-offers-new-treatment-option-for-some-with-severe-mitral-regurgitation-2019042416495https://hhp-blog.s3.amazonaws.com/2018/08/perscription-bottles-pills-300x200.jpg2018-06-06 06:30:112018-06-06 10:30:11https://hhp-blog.s3.amazonaws.com/2018/08/perscription-bottles-pills-300x200.jpgComparing medications to treat opioid use disorderhttps://www.health.harvard.edu/blog/comparing-treat-opioid-use-disorder-2018010313021
https://www.health.harvard.edu/blog/comparing-treat-opioid-use-disorder-2018010313021#commentsWed, 03 Jan 2018 16:00:52 +0000https://www.health.harvard.edu/blog/?p=13021While there are two medications used to treat opioid use disorder that can be prescribed on an outpatient basis, a study comparing them found interesting differences in treatment results.

Using medications to treat opioid use disorder is a lifesaving cornerstone of treatment — much like insulin for type 1 diabetes. The flawed but widely held view that medications like methadone or buprenorphine are “replacing one addiction for another” prevents many people from getting the treatment they need. In actuality, people successfully treated with these medications carefully follow a prescribed medication regimen, which results in positive health and social consequences — as in patients with many types of chronic medical conditions.

However, even among those who embrace treating opioid use disorder (OUD) with medication, there is a difference of opinion as to which medications are most effective. A new study offers important insight into the advantages and disadvantages of the two medications for OUD that can be prescribed in a doctor’s office (that is, on an outpatient basis). These medications are buprenorphine and extended-release (ER) naltrexone. This study was widely covered in the press, and many of the sound bites and headlines reporting the two treatments to be equally effective were a bit misleading.

Buprenorphine is a partial opioid agonist medication. This medication activates the same receptors in the brain as any opioid, but only partly. Because its effects are long-lasting, it can be taken once a day to relieve cravings, prevent withdrawal, and restore normal functioning in someone with opioid use disorder. Because it is a partial agonist, it has a ceiling effect. This means once all the receptors are occupied by the medication, even if a person takes 20 more tablets she wouldn’t feel any additional effect or be at risk of overdose.

Any doctor who has completed special training (a primary care provider, addiction specialist, OB/GYN, etc.) can prescribe buprenorphine. The advantage is, theoretically, that a person with OUD could receive treatment from any provider he or she might see for a routine health issue. I say theoretically because, despite its availability, only about 4% of physicians have done the necessary training to be able to prescribe it. The research on buprenorphine is robust, with multiple studies showing it reduces the risk of death by more than 50%, helps people stay in treatment, reduces the risk that they will turn to other opioids (like heroin), and improves quality of life in many ways.

The advantages and disadvantages of naltrexone (Vivitrol, Revia)

Naltrexone is a pure opioid antagonist. It sticks to an opioid receptor, but instead of activating it to relieve craving and withdrawal it acts as a blocker, preventing other opioids from having any effect. The research on naltrexone has been mixed. Naltrexone in pill form is basically no better than placebo because people simply stop taking it. Studies on extended-release naltrexone are more promising and have shown it to be better than no medication at all. However, there has never been a US trial comparing extended-release naltrexone to either methadone or buprenorphine, until this study.

This study enrolled individuals with opioid use disorder who had voluntarily gone to a detoxification program. Researchers then randomly assigned them to either daily buprenorphine or monthly extended-release naltrexone. Both groups were followed for 24 weeks, to see how many people relapsed.

One of the most important things investigators learned is just how hard it was to get participants onto extended-release naltrexone, revealing a potential barrier to its usefulness. Before a person can start taking ER naltrexone, they must be completely off opioids for seven to 10 days. Only 72% of the group assigned to ER naltrexone even got the first dose, and among those who were randomized during the detoxification process, only 53% started the medication. In contrast, 94% of the group assigned to buprenorphine started the medication.

The other important finding was what happened with relapses. The researchers analyzed their data using an “intention to treat analysis.” This means that once a person is randomly assigned to a treatment (or placebo), their data counts even if they don’t stick with the treatment. Here’s why this is important: if you don’t include that data, then you miss other important outcomes that influence how effective a treatment really is. Thanks to this type of analysis, researchers learned that relapse was significantly more likely in the extended-release naltrexone group (65% compared to 57% in the buprenorphine group).

Immediate relapses were even more likely in the naltrexone group due to failures to start the medication — 25% of the naltrexone group had a relapse on day 21, compared to 3% in the buprenorphine group. Overall there were more overdoses in the naltrexone group, but no difference in fatal overdoses between the groups. Most of the overdoses occurred after the study medication was stopped, highlighting the lifesaving importance of getting on, and staying on, treatment. The naltrexone group also had a longer length of stay in inpatient detoxification programs, which may be an important consideration when we think about overall healthcare costs.

So, why did many headlines claim extended-release naltrexone was as effective as buprenorphine? Well, that was the finding of a separate analysis that looked only at people who successfully started each medication. When the data was viewed that way, there was no difference between the two medications, but that’s just part of the picture. If it’s harder to get a person to successfully start and stick with a medication, that should factor in evaluating its “effectiveness.”

Take-home messages from X-BOT

This is an incredibly important study. The findings are generally consistent with what I see in my clinical practice. Overall buprenorphine is a more effective treatment for opioid use disorder, in part because it’s easier to get patients started on it and they are more likely to stick with it. Extended-release naltrexone may be as good for people who can successfully complete the detoxification required before starting on it. Both medications have a place, but as with so many conditions and treatments, one size does not fit all.

]]>https://www.health.harvard.edu/blog/comparing-treat-opioid-use-disorder-2018010313021/feed613021https://www.facebook.com/sharer/sharer.php?u=https%3A%2F%2Fwww.health.harvard.edu%2Fblog%2Fcomparing-treat-opioid-use-disorder-2018010313021]]>Involuntary treatment for substance use disorder: A misguided response to the opioid crisishttps://www.health.harvard.edu/blog/involuntary-treatment-sud-misguided-response-2018012413180https://hhp-blog.s3.amazonaws.com/2018/01/iStock-879166858.jpg2018-01-03 11:00:522018-01-03 16:00:52Alcohol use disorder: When is drinking a problem?https://www.health.harvard.edu/blog/alcohol-use-disorder-when-is-drinking-a-problem-2018122015585https://hhp-blog.s3.amazonaws.com/2018/01/iStock-879166858.jpg2018-01-03 11:00:522018-01-03 16:00:52Mind-body therapies can reduce pain and opioid usehttps://www.health.harvard.edu/blog/mind-body-therapies-can-reduce-pain-and-opioid-use-2020021118772https://hhp-blog.s3.amazonaws.com/2018/01/iStock-879166858.jpg2018-01-03 11:00:522018-01-03 16:00:52Can probiotics help treat depression and anxiety?https://www.health.harvard.edu/blog/can-probiotics-help-treat-depression-anxiety-2017072612085https://hhp-blog.s3.amazonaws.com/2018/01/iStock-879166858.jpg2018-01-03 11:00:522018-01-03 16:00:52How to treat a child’s sunburnhttps://www.health.harvard.edu/blog/how-to-treat-a-childs-sunburn-2018070314178https://hhp-blog.s3.amazonaws.com/2018/01/iStock-879166858.jpg2018-01-03 11:00:522018-01-03 16:00:52https://hhp-blog.s3.amazonaws.com/2018/01/iStock-879166858.jpgSaving lives by prescribing naloxone with opioid painkillershttps://www.health.harvard.edu/blog/saving-lives-prescription-prescribing-naloxone-opioid-painkillers-2016082610075
https://www.health.harvard.edu/blog/saving-lives-prescription-prescribing-naloxone-opioid-painkillers-2016082610075#commentsFri, 26 Aug 2016 13:30:09 +0000http://www.health.harvard.edu/blog/?p=10075Unintentional opioid overdose is now the leading cause of accidental death in the United States. These drugs are prescribed to patients to help relieve pain, but overdoses happen because opioids can also depress breathing, sometimes stopping it altogether. But naloxone, also called Narcan, can help reverse the effects of an overdose. If doctors prescribe naloxone at the same time as opioids, overdose deaths may decrease.

Opioid drugs help relieve pain by sticking to opioid receptors in the body, which in turn, helps block “pain signals.” The umbrella term “opioids” includes prescription painkillers, such as hydrocodone (in Vicodin) or oxycodone (in Percocet), as well as heroin. These drugs not only ease pain and cause pleasurable feelings, but also can depress breathing — take too much and a person can stop breathing altogether and will die without quick treatment.

Unintentional overdose is now the leading cause of accidental death in the United States. As more Americans are prescribed opioids for chronic pain, these medications increasingly find their way into the community. This has led to a rise in the non-medical use of these drugs. In 2014, 10.3 million people reported taking prescription opioids that were not prescribed for them, or for reasons other than the condition the medication was intended to treat. As a result, emergency department visits related to the misuse of prescription opioids have tripled, and deaths related to prescription opioids have quadrupled since the early 2000s.

We desperately need ways to prevent these accidental deaths.

What is naloxone?

Naloxone, also called Narcan, is a medication that immediately reverses the effects of opioids in the brain. As a result, it can rescue someone from an overdose instantly. It can be given as a nasal spray or a muscular injection (like an Epi-pen used for severe allergic reactions). Its use among people who use illegal opioids has reduced the number of deaths due to overdose. Anyone with a minimal amount of training can give the naloxone, and it won’t cause harm if given to someone who has not taken opioids. Early on, there were concerns that the availability of naloxone might increase opioid use. That has not turned out to be the case, in part because the drug causes an unpleasant sensation of withdrawal when given to someone who has used opioids. Naloxone programs have proved successful, but they typically are intended for people who use non-prescribed opioids.

Can naloxone help protect people taking prescribed opioids?

But people who use opioids prescribed by their doctors are also at risk of overdose. Is there a role for naloxone serve as a safeguard for these patients?

A recent study in the Annals of Internal Medicine explored the potential benefits of prescribing naloxone along with opioids — an approach called “co-prescribing.” Here’s how it works. Providers educate patients who take opioids for chronic pain about the risks of overdose and teach them how to use naloxone. And then prescribe both drugs at the same time.

In this study, researchers trained staff at six clinics in the San Francisco area on how to co-prescribe opioids and naloxone. They then looked at how often naloxone was actually prescribed, whether co-prescribing translated in fewer emergency department visits related to opioids, and whether the dose of prescribed opioids changed. Here’s what the study found:

When providers were trained in this approach, the number of naloxone prescriptions increased. So doctors seemed willing to co-prescribe.

Patients who were on higher dosages of opioids or had been to the emergency department in the past year because of opioids were more likely to get prescribed naloxone.

Compared to the people who did not receive a naloxone prescription, those who did had 47% fewer emergency department visits per month in the subsequent six months.

Receiving naloxone had no effect on the dose of prescribed opioids.

Putting the results into action

The results of this study suggest that naloxone may help curb the potentially devastating risks of opioid misuse — and that doctors are willing to prescribe it along with opioids.

There’s more encouraging news. Co-prescribing seems like a viable option. A relatively brief training for providers was enough to result in a third of patients on opioids for chronic pain receiving a naloxone prescription. The fact that those on higher dosages and with previous ER visits were more likely to get a prescription likely means that providers were particularly willing to co-prescribe to patients they perceived to be at high risk. However, doctors appeared less likely to co-prescribe for their elderly or black patients. Given that overdoses occur among all ages and ethnicities, this is a concern and highlights the need for more uniform protocols to ensure naloxone is made available to all patients at risk. The reduction in emergency visits is particularly interesting and may be due to the positive effects of simply talking explicitly about overdose and medication risks. It could also be because having naloxone on hand meant patients didn’t need to go to the emergency department for an overdose.

Given the relative safety of naloxone and the death toll from opioids across this country, co-prescription of naloxone with opioid pain medication makes a lot of practical sense. Any opportunity to discuss the risks of opioids, how to identify and respond to an overdose, and how to use naloxone is beneficial. These discussions are important not just for patients taking opioids for chronic pain, but also for their friends, family, and community members.

]]>https://www.health.harvard.edu/blog/saving-lives-prescription-prescribing-naloxone-opioid-painkillers-2016082610075/feed310075https://www.facebook.com/sharer/sharer.php?u=https%3A%2F%2Fwww.health.harvard.edu%2Fblog%2Fsaving-lives-prescription-prescribing-naloxone-opioid-painkillers-2016082610075]]>Naloxone: An important tool, but not the solution to the opioid crisishttps://www.health.harvard.edu/blog/naloxone-tool-not-solution-opioid-crisis-2017113012800https://hhp-blog.s3.amazonaws.com/2016/08/Naloxone-Narcan-EDITORIAL-ONLYshutterstock_648230575.jpg2016-08-26 09:30:092016-08-26 13:30:09Should you carry the opioid overdose rescue drug naloxone?https://www.health.harvard.edu/blog/should-you-carry-the-opioid-overdose-rescue-drug-naloxone-2018050413773https://hhp-blog.s3.amazonaws.com/2016/08/Naloxone-Narcan-EDITORIAL-ONLYshutterstock_648230575.jpg2016-08-26 09:30:092016-08-26 13:30:09Asking saves lives: A simple question can keep children safe from gun injuryhttps://www.health.harvard.edu/blog/asking-saves-lives-a-simple-question-can-keep-children-safe-from-gun-injury-2017062011913https://hhp-blog.s3.amazonaws.com/2016/08/Naloxone-Narcan-EDITORIAL-ONLYshutterstock_648230575.jpg2016-08-26 09:30:092016-08-26 13:30:09Real-life healthy dinners (for real people with real busy lives)https://www.health.harvard.edu/blog/real-healthy-dinners-busy-people-2017112912794https://hhp-blog.s3.amazonaws.com/2016/08/Naloxone-Narcan-EDITORIAL-ONLYshutterstock_648230575.jpg2016-08-26 09:30:092016-08-26 13:30:09Can short bouts of running lengthen lives?https://www.health.harvard.edu/blog/can-short-bouts-of-running-lengthen-lives-2020030419058https://hhp-blog.s3.amazonaws.com/2016/08/Naloxone-Narcan-EDITORIAL-ONLYshutterstock_648230575.jpg2016-08-26 09:30:092016-08-26 13:30:09https://hhp-blog.s3.amazonaws.com/2016/08/Naloxone-Narcan-EDITORIAL-ONLYshutterstock_648230575.jpgWords matter: The language of addiction and life-saving treatmentshttps://www.health.harvard.edu/blog/words-matter-language-addiction-life-saving-treatments-2016081510130
https://www.health.harvard.edu/blog/words-matter-language-addiction-life-saving-treatments-2016081510130#commentsMon, 15 Aug 2016 13:30:45 +0000http://www.health.harvard.edu/blog/?p=10130The challenges of drug addiction are compounded by stigmatizing language and incorrect perceptions about the medications used in addiction treatment. Viewing addiction as a disease and likening it to other chronic diseases can help remove the negative connotations from the illness.

News articles, radio, and television frequently report on the current opioid crisis. As the death toll has mounted, the media has importantly covered many aspects of the crisis. Unfortunately, this coverage often focuses on the very visible individuals who continue to struggle with active addiction. What is missing is a narrative of hope for a chronic disease which is as treatable as diabetes or high blood pressure.

In addition to the pessimistic portrait painted about addiction, the language used by the media is often problematic. Articles frequently use the term “abuse” or “abuser” or refer to individuals as “addicts.” Even the term “clean” is laden when referencing sobriety, as it implies that someone who is actively using is somehow “dirty.”

Language matters–a lot

The use of “abuse” and “abuser” has been shown to increase stigma even among highly trained clinicians, who recommend more punitive treatment when an individual is described that way. We do not call patients with diabetes “sugar abusers,” nor do we say their blood is “dirty” with sugar. Describing patients as having a substance use disorder demonstrates that their illness does not define them, just as we should no longer call a person with schizophrenia a “schizophrenic.”

The language we use related to addiction treatment also impacts stigma. Methadone and buprenorphine are lifesaving, effective medications for opioid use disorder. Their use reduces relapse and death far more than any other available treatment. And yet they are frequently referred to as “replacements,” worsening the mistaken notion that these medications are simply a way to substitute a legal opioid for an illicit opioid. They are not. Addiction is a behavioral syndrome characterized by compulsive drug use despite negative consequences. Patients successfully treated with methadone no longer meet the criteria for active opioid use disorder. Taking a medication to manage an illness is the hallmark of chronic disease treatment. Individuals taking medication to successfully treat addiction are physically dependent, just as someone taking insulin for diabetes requires a daily shot to be able to function normally. Both will get sick if they stop their medication. But someone on methadone is no more “addicted” than any person who relies on a daily prescription to keep a chronic disease under good control.

Stigma can deter people from treatment

In Boston, the term “methadone mile” has come to refer to a stretch of Massachusetts Avenue where the devastation of active drug use is highly visible. This reference is particularly unfortunate because it lumps those on treatment for opioid use disorder with those actively using. This insinuation that individuals on methadone maintenance are no different than those actively using heroin is incredibly stigmatizing and is one reason why many won’t consider this treatment.

Methadone was first discovered in 1965 through the groundbreaking research of scientists at the Rockefeller Institute. Those early studies demonstrated methadone’s remarkable ability to alleviate withdrawal and craving while dramatically improving the ability to function emotionally and socially. In the subsequent decades, the evidence supporting methadone’s positive effects has grown. These include significant reductions in drug use, new HIV infection, crime, and death from overdose. The research is so strong that methadone, along with buprenorphine (Suboxone), has been added to the World Health Organization’s list of essential medications. And yet despite this, only a minority of programs offer methadone treatment and the undeserved shame associated with this lifesaving medication persists.

Many would be surprised to learn that most people with a substance use disorder will get better, and the lifesaving medications methadone and buprenorphine are the most effective pathway to recovery, not detoxification. Those doing well on medication are often invisible because they are scared to share their pathway to treatment in the face of such misunderstanding.

Words matter and continued use of stigmatizing language perpetuates false stereotypes, spreads misinformation, and keeps people out of care.

]]>https://www.health.harvard.edu/blog/words-matter-language-addiction-life-saving-treatments-2016081510130/feed1510130https://www.facebook.com/sharer/sharer.php?u=https%3A%2F%2Fwww.health.harvard.edu%2Fblog%2Fwords-matter-language-addiction-life-saving-treatments-2016081510130]]>Leaving time for last wordshttps://www.health.harvard.edu/blog/leaving-time-for-last-words-2018092414832https://hhp-blog.s3.amazonaws.com/2016/08/positive-addiction-language-blog.jpg2016-08-15 09:30:452016-08-15 13:30:45A mix of treatments may extend life for men with aggressive prostate cancerhttps://www.health.harvard.edu/blog/mix-treatments-may-extend-life-men-aggressive-prostate-cancer-2018033113521https://hhp-blog.s3.amazonaws.com/2016/08/positive-addiction-language-blog.jpg2016-08-15 09:30:452016-08-15 13:30:45Your risk of dementia: Do lifestyle and genetics matter?https://www.health.harvard.edu/blog/your-risk-of-dementia-do-lifestyle-and-genetics-matter-2019091317671https://hhp-blog.s3.amazonaws.com/2016/08/positive-addiction-language-blog.jpg2016-08-15 09:30:452016-08-15 13:30:45Food allergy, intolerance, or sensitivity: What’s the difference, and why does it matter?https://www.health.harvard.edu/blog/food-allergy-intolerance-or-sensitivity-whats-the-difference-and-why-does-it-matter-2020013018736https://hhp-blog.s3.amazonaws.com/2016/08/positive-addiction-language-blog.jpg2016-08-15 09:30:452016-08-15 13:30:45Mind over matter? How fit you <em>think</em> you are versus actual fitnesshttps://www.health.harvard.edu/blog/mind-over-matter-how-fit-you-think-you-are-versus-actual-fitness-2017081412282https://hhp-blog.s3.amazonaws.com/2016/08/positive-addiction-language-blog.jpg2016-08-15 09:30:452016-08-15 13:30:45https://hhp-blog.s3.amazonaws.com/2016/08/positive-addiction-language-blog.jpgFentanyl: The dangers of this potent “man-made” opioidhttps://www.health.harvard.edu/blog/fentanyl-dangers-potent-man-made-opioid-2016080510141
https://www.health.harvard.edu/blog/fentanyl-dangers-potent-man-made-opioid-2016080510141#commentsFri, 05 Aug 2016 13:30:48 +0000http://www.health.harvard.edu/blog/?p=10141Fentanyl is a powerful synthetic opioid. It is far more potent — and potentially more dangerous — than heroin and morphine. Overdose deaths related to fentanyl are on the rise. The drug is cheaper than heroin and recently is being used to dilute heroin or substitute for it. Users may be unaware that they are taking this potent drug, or may even seek its intense high. People at risk from using fentanyl can be treated successfully with therapies used for other opioid use disorders, but taking steps to prevent overdose are critical until a person is ready to seek care.

As we watch the devastation of the opioid crisis escalate in a rising tide of deaths, a lesser known substance is frequently mentioned: fentanyl. Fentanyl’s relative obscurity was shattered with the well-publicized overdose death of pop star Prince. Previously used only as a pharmaceutical painkiller for crippling pain at the end of life or for surgical procedures, fentanyl is now making headlines as the drug responsible for a growing proportion of overdose deaths.

So what is fentanyl and why is it so dangerous?

Fentanyl is a synthetic opioid, meaning it is made in a laboratory but acts on the same receptors in the brain that painkillers, like oxycodone or morphine, and heroin, do. Fentanyl, however, is far more powerful. It’s 50-100 times stronger than heroin or morphine, meaning even a small dosage can be deadly.

Its potency also means that it is profitable for dealers as well as dangerous for those who use it, intentionally or unintentionally. Increasingly heroin is being mixed with fentanyl so someone who uses what they think is heroin may in fact be getting a mixture with — or even pure — fentanyl. More recently, pills made to look like the painkiller oxycodone or the anxiety medication Xanax are actually fentanyl. This deception is proving fatal. It would be like ordering a glass of wine and instead getting a lethal dose of pure ethanol. While many people don’t know they are getting fentanyl, others might unfortunately seek it out as part of the way the brain disease of addiction manifests itself into compulsively seeking the next powerful high.

Helping people who use fentanyl

The way to help patients who are using fentanyl is the same as for other forms of opioid use disorder: to provide effective addiction treatment. However, the first and most important step is helping patients stay safe and stay alive until we can get them that treatment.

It’s worth remembering that dead people don’t recover.

To stop the deaths, we must provide immediate access to lifesaving treatment on demand. While any opioid use is risky, fentanyl has raised the stakes. Every single episode of fentanyl use carries the risk of immediate death. This highlights the need to change how we think about treatment. Many of the traditional models of addiction treatment were designed for alcohol use disorder. Misuse of alcohol can be fatal, but it usually takes many years or even decades to kill someone. In contrast, opioid addiction is imminently fatal, so waiting for treatment is and should be considered unacceptable. We must try to initiate treatment at every opportunity — in the emergency department, at the hospital bed, or even on the street. The best evidence we have shows that a combination of medication and psychosocial treatments is most effective for opioid use disorder. A study of MassHealth patients found that patients on medication treatments like methadone or buprenorphine are 50% less likely to relapse. Other studies have shown that patients treated with these medications are 50% (or more) less likely to die. And yet significant stigma and misunderstanding still exists around these medications. We have treatment programs (and doctors) that don’t offer these medications and patients who are doing wonderfully in recovery thanks to them, but who are also scared to speak out and say they are on medication because the stigma is so pervasive.

Even with our best efforts, it can take time for some people to be open to treatment. In those cases, our priority is to keep them alive and to keep working with them on their readiness to consider treatment. This requires access to naloxone, the antidote to overdoses. But it also includes other education and harm reduction services. People who have loved ones who are actively using and those who are using themselves need to know how to stay safe. There is very concrete education that can reduce the risk of overdose and we need to ensure it is getting to those at the greatest risk.

Moving forward

In Massachusetts alone, deaths due to fentanyl overdose have risen to 57% between 2015 and the first half of 2016. These deaths are yet another symptom of the broader epidemic of opioid addiction. Just as deaths from AIDS are due to untreated HIV, deaths from overdose are frequently due to untreated addiction. Prince’s death is a reminder that opioid addiction is a disease that can and does affect people from all economic classes and all walks of life.

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